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Rapid Responses: Rapid Responses published:
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interesting article
- Susan Hughes (12 March 2004)
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Validity is flawed - what about the laws of gravity and bouyancy?
- Sara S Webb, Aishah Bibi, Bearnadette Earley (8 April 2004)
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We need more trials like this, but
- Karen Leitzel (21 October 2004)
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Help for the posterior baby
- Esther Marilus (9 March 2007)
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Susan Hughes, student midwife Hope Hospital Salford, Manchester
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The findings of this article did not surprise me and I feel that the exercises (hands and knees positioning) used until labour are beneficial for women, not merely to rotate an occiput posterior position prior to labour, but to continue to use this exercise DURING labour. I have witnessed numerous occiput posterior postion fetus' rotate to occipt anterior position during labour; this suggests further research is required before ceasing to advise women not to use the hands and knees postion. Interesting article. Competing interests: None declared |
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Sara S Webb, Midwife Birmingham Women's Healthcare NHS Trust, Metchley Park Road, Edgbaston, Birmingham, B15 3TG, Aishah Bibi, Bearnadette Earley
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Dear Editor Kariminia et al (2004) claim that hands and knees posturing is ineffective in reducing the incidence of occiput-posterior positions at birth in a randomised controlled trial, an approach research deserving more frequent application in evaluation of midwifery interventions (1). However, due to lack of clarity about how the posturing was applied we are uncertain about the validity of their claim. The use of hands and knees posturing, otherwise referred to as the 'all fours posture', is widely used by midwives. It is surprising that Kariminia et al (2004) refer to it as an intervention based on personnel belief (1). The use of the all fours posture has long been supported by the laws of physics and physiology (2). The law of gravity states that all objects are drawn towards the earth, and that the acceleration of movement is dependent on the mass and the availability of space. If this is applied to the fetus where the mother has adopted the all fours posture the heaviest poles of the fetus (the trunk and the occiput) would be drawn towards the earth, and into an anterior position. Such movement would be hindered only in two cases; [1] if the mass (the fetus) was not heavy enough to exert a force of acceleration or [2] if there was no available space into which the mass (fetus) could move. It appears that such principles were not considered by the authors for the intervention used in their study. Firstly, by implementing the intervention at 37 weeks, the availability of space was restricted. Midwifery practice advocates such intervention at 34-35 weeks when more space is available. Secondly the intervention was not implemented when the fetus was in an active state, which would have encouraged further movement of an already moving object. Another very important principle that was neglected related to the specific nature of the associated rocking with the all-fours posture. If 'rocking' equates to swaying of the pelvis from side to side this would exert only a frictional force which, solely, would not be of great benefit. If, however, posturing included movement of the maternal trunk backwards and forwards whilst on all fours this would both increase the available space at the pelvic inlet and along with gravitational and buoyancy forces will encourage frictional movement (3). As the mother moves her trunk forward, her spine is encouraged to move away whilst the maternal symphasis drops down, thus increasing the available space in the pelvic inlet and allowing the fetus more room to rotate to an anterior position. If the study intervention did not consider any of these vital principles, it is hardly surprising that the result of the trial was negative. At best what the authors can claim is that their particular form of maternal posturing was both ineffective at decreasing the incidence of occiput-posterior position at birth and painful to the study participants. It cannot by any means be concluded that appropriate hands and knees exercise should be discontinued as a way of changing fetal position. No doubt further research is required, but it would be a mistake to use this study alone as a rationale for dismissing maternal posturing as a potentially effective means of changing fetal position. Aishah Bibi, Registered Midwife
Birmingham Women’s Healthcare NHS Trust,
Metchley Park Road,
Edgbaston,
Birmingham
B15 2TG
Competing Interests: None declared References (1) Kariminia et al (2004) Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. British Medical Journal 2004(328) pp.490-493 (2) Barnum C G (1915) The effect of gravitation on the presentation and position of the fetus. Journal of the American Medical Association. 64 pp.498-502 (3) Sears F W & Zemansky M W (1960) College Physics (3rd Edition) Addison-Wesley Publishing Company, Reading, Mass. Competing interests: None declared |
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Karen Leitzel, family physician Crown Point, IN 46307 (USA)
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I applaud the authors, as this type of randomized controlled trial is all too rare. Often what one might call patient-implemented and non-invasive birthing maneuvers are scientifically untested and remain in the realm of anecdote and expert opinion. Such interventions are usually based on a good deal of observation and "common sense" but as we know RCTs may uncover hidden pitfalls to the approach or show that the desired effect is not produced to any worthwhile degree. However, this particular trial does not seem to ask the questions many would probably like answered. The participants spent ten minutes twice daily from 37 weeks GA to labor in all-fours positioning. I wish the study had used longer times (30 min?) and addressed the issue of conversion to OA during labor vs. persistent OP. Still, it's a good start. Competing interests: None declared |
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Esther Marilus, Labor Therapist, writer 8004 Zurich Switzerland
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Mothers who read this study should not despair. If simply going on hands and knees fails to turn an OP(Occiput Posterior) baby around - other exercises will and are surely worth a try, considering all the risks of being born OP. Statistics show that labor takes longer and is more traumatic to both the newborn and the mother when a baby who begins labor looking up (OP) persists that way until the end of the birth canal. Labor is also much longer for the OP (Occiput Posterior) baby who does manage to turn around somewhere along the way*. Another large scale study**,based on 2,591 neonates delivered in an occiput posterior position, found that neonatal outcome is significantly worse for these babies than for those born in non-posterior positions. OP babies in this retrospetive cohort study, scored lower on their second, 5 minute, Apgars and were more likely to be born with meconium and more academic cord gases. They were also sent to the intensive care nursery more often and stayed there longer than their non-posterior peers. Statistics also consistently show the OP baby to be a notorious ‘Johnny come lately’; missing his due date and ending up being chemically induced more often than not. My own experience as a labor therapists,has shown that many of the post- term mothers who come to my studio hoping to bring on labor through exercise before being induced, are carrying a fetus who is posterior. We can see the eyes staring up at us from the ultrasound screen we take before we begin. After exercising, the same screen almost always shows the same fetus - minus the eyes - in the preferred Occiput Anterior lie. Working with real-time ultrasound takes much of the guesswork out of my materanl maneuers. They either work or they don't. There is no going home to keep on exercising for so many minutes every day. Butif a mother would repeat the same maneuvers later on chances of her baby's turning back are highly unlikely; which might not be the case with the popular on-all-4's position. Might this not explain the poor outcome of this particular test trial? After all, if going down on-all-4's can turn an OP into an OA baby, why shouldn’t it work the other way around? Certainly for a fetus the sudden change in his mother's position turns his world upsdie down;literally pulling the rug out from under and sending him tumbling down into a freefall. Fortunately there are gentler, more controlled maneuvers to get the same job done, which is why I reserve on-all-4’s for other complications; still, it would be naïve to assume that going on hands and knees had no affect on a fetus or his lie, as the authors of this study do. Contact address: safe@012.net.il *Influence of Persistent Occiput Posterior Position on Delivery Outcome Myra Fitzpatrick, MRCOG, Kathryn McQuillan, RGN and Colm O’Herlihy, MD, FRC **"The Association Between Persistent Occiput Posterior POsition and Neonatal Outcomes" Yvonne W. Cheng, Brian L. Shaffer, Aaron B. Caughey, Competing interests: None declared |
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